TEST 2 - UNIT B - EF - PRIORITY SETTING FRAMEWORKS Flashcards
Nurses should use clinical indicators such as
level of consciousness, trending of vital signs, skin color, pain level, and gastrointestinal changes to guide clinical decision making in determining a client’s clinical status.
Although the ABCDE approach has traditionally been used in the acute care setting, it can be used in any
health care setting to assess and treat acutely ill clients.
ABCDE framework places the highest priority o
n ensuring an adequate airway.
Rationing of care can occur due to
inadequate resources, including time, staffing levels, and staff mix.
Rationing of care means that
care is left undone, omitted, or missed due to limited resources.
Missed care is considered
a medical error that can potentially affect client safety.
Delegation of client care to other members of the interprofessional team is an option when
prioritizing client care, as it
gives the nurse more time to care for clients who have higher-acuity needs.
A nurse may not delegate any task that requires either
nursing judgment or critical decision making.
When implementing safety and risk reduction as a priority framework, nurses should choose to
intervene first in the situation that poses the greatest risk for injury to a client.
When prioritizing care for a group of clients, nurses should
first rank the order in which clients should be seen, and then rank the order of care tasks for each individual client.
To prioritize a group of clients in an ED, the nurse
first collects initial focused client data and assigns an acuity level to the client.
Most EDs utilize a five-level acuity system that ranks clients who are
severely ill at level 1 and clients who are least ill at level 5.
Nurses can assist with triage of groups of clients in the community following a mass-casualty event by using the
survival potential priority-setting framework.
Mass-casualty triage differs from ED triage, in that
the most critically injured clients might receive no treatment if they have minimal chance of survival.
ABCDE (airway, breathing, circulation, disability, exposure) approach
A systematic method that can be utilized in any health care setting to evaluate and treat the client. ABCDE is the acronym for airway, breathing, circulation, disability, and exposure.
acute versus chronic
A framework in which acute conditions are prioritized over chronic conditions.
direct care
Client care activities that are performed at the bedside.
indirect care
Client care activities performed by the nurse away from the bedside.
least restrictive/least invasive
Interventions are selected that maintain client safety while producing the least amount of restriction to the client;the nurse chooses interventions that are the least invasive.
Maslow’s hierarchy of needs
A theory that suggests there are five categories of needs that motivate human beings. The five categories are psychological, safety, love and belonging, esteem, and self-actualization.
nursing process
A framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.
rationing
Process in which allocated resources are scarce and there will not be enough to meet all of the required needs.
resource allocation
The distribution of resources to a service or department.
safety and risk reduction
Priority is given to whatever finding poses the greatest or immediate risk to the client’s physical or psychological well-being.
survival potential
Priority is given to the client who has a reasonable chance of survival with immediate intervention. This framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage.
triage
To sort and rank treatment of clients according to the urgency of their need for care.
unstable versus stable
Priority is given to the client who has an unstable condition versus the client with a stable condition.
urgent versus nonurgent
Priority is given to the client who has an urgent need over a client with a nonurgent need.
Hypertension is a chronic disorder; therefore, there is another client that the nurse should recommend as the priority for treatment.
DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT
When using the acute vs chronic approach to client care, the nurse should recommend a client who reports new chest pain as the
priority for treatment. The client might be experiencing a myocardial infarction, which could result in poor outcomes if not identified and treated immediately.
Arthritis is a chronic disorder and joint stiffness is an expected finding; therefore, there is another client that the nurse should recommend as the priority for treatment.
DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT
Diabetes mellitus is a chronic disorder; therefore, there is another client that the nurse should recommend as the priority for treatment.
DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT
A client who is scheduled for an abdominal ultrasound has a
nonurgent need; therefore, there is another client that the nurse should see first.
A client who needs a urine specimen sent to the lab has a
non-urgent need; therefore, there is another client that the nurse should see first.
When using the urgent vs. nonurgent approach to client care, the nurse should determine that they should first see a client who has
audible wheezing during respiration.
AUDIBLE WHEEZING - PRIORITY BECAUSE
This client’s airway is partly compromised, and their condition could worsen quickly without urgent intervention.
A client who is requesting their routine pain medication has a
non-urgent need; therefore, there is another client that the nurse should see first.
The nurse might need to apply soft limb restraints to the client’s wrists to prevent the client from pulling the IV out; however, the nurse should
use a less restrictive intervention first.
The nurse might need to administer a medication to sedate the client, such as an antianxiety medication, to prevent the client from pulling the IV out; however, the nurse
should use a less invasive intervention first.
When using the least restrictive/least invasive priority setting framework, the nurse should use the
least restrictive or least invasive intervention before other more invasive or restrictive ones.
An elastic bandage will
hide the IV from the client’s vision while at the same time allowing the nurse easy access to the site.
The nurse might need to request a prescription for a central venous catheter; however, the nurse should
use a less invasive intervention first. Invasive procedures increase the risk of client harm.
Invasive procedures increase the
risk of client harm.
MASS CASUALTY SITE: A client who reports a possible sprained wrist and is walking around does not have
an immediate threat to life and can wait for treatment; therefore, there is another client the nurse should recommend for transport first.
MASS CASUALTY SITE: A client who has an open forearm fracture without visible drainage does not
have an immediate threat to life and can wait for treatment; therefore, there is another client the nurse should recommend for transport first.
MASS CASUALTY SITE: A client who has a respiratory rate of 6/min and no pupil response has a
minimal chance of survival even with intervention; therefore, there is another client the nurse should recommend for transport first.
MASS CASUALTY SITE: A client who has an abdominal wound that is actively bleeding requires
immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend this client for first transport to a health care facility.
A client who is hemorrhaging has
an immediate threat to life.
Developing a nursing diagnosis, or analysis, is the _______ step of the nursing process.
second
The first action the nurse should take when using the nursing process is to
assess the client.
Assessment of the client includes a
physical examination, client interview, review of the medical records, and general observation.
A registered nurse uses a
five-step sequential nursing process, which includes assessment, analysis, planning, implementation, and evaluation.
Performing nursing interventions is the ____ step in the nursing process.
fourth
Developing goals and outcomes is the ___ step in the nursing process.
third
A client who is receiving a blood transfusion and reports urticaria is
unstable because this is a manifestation of anaphylaxis; therefore, the nurse should plan to see this client first. Anaphylaxis is a life-threatening condition that requires immediate attention.
Anaphylaxis -
life-threatening condition that requires immediate attention.
A client who has back pain and is requesting a muscle relaxant is
stable; therefore, there is another client that nurse should plan to see first.
A client who has an ankle sprain and requests toileting assistance is prioritized
stable; therefore, there is another client that the nurse should plan to see first.
A client who has chronic migraines and reports a headache is
stable; therefore, there is another client that the nurse should plan to see first.
The nurse should recognize that love and belonging needs are motivated by the need for
social relationships. These needs come after safety and security needs.
The nurse should recognize that self-actualization needs are motivated by the
need for self-fulfillment, or to reach one’s maximum potential and are only reached after all other needs have been met.
The nurse should recognize that safety needs are motivated by the need for
security of the environment, personal security, and employment and must be met before addressing a client’s self-esteem needs.
The nurse should recognize that self-esteem needs are motivated by the need to
feel good about one’s self and have the respect of others.
If self-esteem needs are unfilled, the client may experience a feeling of
inferiority.
This client reports a new onset of abdominal pain, which would be considered an
progress and worsen over an extended period.
acute condition
, or a condition that appears suddenly and can worsen rapidly.
The nurse should categorize NEW OSET OF ABDOMINAL PAIN AS ______________ if using the survival potential framework, rather than minimal.
DELAYED
Clients who are tagged as minimal have a condition that can
wait hours to days for treatment. This client reports a new onset of abdominal pain, which requires investigation to determine the cause.
Conditions in the urgent category
have a greater probability of poor outcomes if prompt actions are not taken.
Abdominal pain can be caused by
non-life-threatening problems such as gas and constipation but can also be a manifestation of more significant illnesses such as bowel obstruction or appendicitis. The nurse should assess the client further to determine the cause of the abdominal pain.
Clients who are tagged as expectant have a condition that is
likely to cause death despite treatment.
Physiological needs are the
highest priority (Level 1).
Physiological needs take priority over other needs because they are
essential for survival. The nurse should not address any other needs until physiological needs have been met.
Safety needs are the
second level of priority in Maslow’s Hierarchy of Needs (Level 2). Once physiological needs have been met, the nurse should plan to meet safety needs.
Love and belonging are the are the
third level of priority in Maslow’s Hierarchy of Needs (Level 3). After physiological and safety needs have been met, the nurse should address love and belonging.
Esteem needs are the
fourth level of needs in Maslow’s Hierarchy of Needs (Level 4). The nurse should focus on esteem needs once the client has satisfied the need for love and belonging.
Self-actualization is the
fifth level of needs in Maslow’s Hierarchy of Needs (Level 5). Only after all other needs have been satisfied will an individual be ready to turn their attention to self-actualization. The nurse should recognize that self-actualization is the lowest priority of need.
Report of dizziness when standing indicates that
this client is at greatest risk for injury from a fall; therefore, this is the priority finding. The nurse should implement the nursing process to determine the cause of dizziness and implement fall precautions.
Non pitting edema on lower extremtieis
This finding does not pose an immediate threat to the client’s physical or psychosocial well-being. The nurse should implement interventions to decrease the edema in the client’s lower extremities; however, another finding is the priority.
scratch marks on abdomen
This finding does not pose an immediate threat to the client’s physical or psychosocial well-being. The nurse should collect subjective data from the client about the scratch marks on the client’s abdomen; however, another finding is the priority.
When completing the exposure component of the ABCDE priority setting method, the nurse should observe
the client from head-to-toe for abnormalities. This includes the client’s lower extremities for indications of deep vein thrombosis such as pain, edema, and erythema of the calf area.
When completing the exposure component of the ABCDE priority setting method, obtaining a respiratory rate is
ncorrect.
The nurse should obtain a respiratory rate, including depth and pattern of respirations, when completing the _____________ of the ABCDE priority setting method. In addition, the nurse should also auscultate lung sounds, observe for chest wall symmetry during inspiration and expiration, and check for presence of retractions.
breathing component
When completing the exposure component of the ABCDE priority setting method, the nurse should measure the client’s _________. An elevated _________ might indicate that the client has a current infection or other inflammatory process.
temperature
temperature
The nurse should monitor the client for manifestations of bleeding such as bruising or abdominal distention in the
exposure component of the ABCDE priority setting method.
The nurse should obtain a blood pressure measurement when completing the _______ component of the ABCDE priority setting method. In addition, the nurse should check pulse rate and quality.
circulation
A client who received digoxin and has a heart rate of 48/min is
unstable; therefore, the nurse should identify this client as the priority for care. This heart rate is below the expected reference range. The nurse should report this finding to the provider and check for manifestations of decreased cardiac output.
A client who is received pain medication and has a respiratory rate of 14/min is
stable; therefore, there is another client the nurse should identify as the priority for care. This respiratory rate is within the expected reference range.
A client who has a urinary tract infection and temperature of 37.9° C (100.2° F) is
stable; therefore, there is another client the nurse identify as the priority for care. This temperature is within the expected reference range.
A client who has anemia and a blood pressure of 118/78 mm Hg is
stable; therefore, there is another client the nurse should identify as the priority for care. This blood pressure is within the expected reference range.
ABCDE approach - The nurse should assess the client’s body temperature as part of
step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.
ABCDE approach - The nurse should assess the client’s abdominal contour for
alterations, such as distention, as part of step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.
ABCDE approach - The nurse should assess the client’s skin integrity for
alterations such as the rashes, or lesions, as part of step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.
When using the ABCDE approach to client care, the nurse should determine to next assess the client’s
circulatory status after airway and breathing status.
Indicators of circulatory function can include
taking a blood pressure, checking peripheral pulses, and measuring capillary refill time.
The nurse should use the acute vs. chronic framework when trying to
determine if a client is experiencing a sudden condition change or manifestations of a long-term condition.
The nurse should first care for clients experiencing _______ before caring for those experiencing _____
acute conditions
chronic conditions.
Since this client is experiencing manifestations in multiple body systems, the nurse should use the
ABCDE framework to prioritize which assessment to perform first.
The ABCDE method prioritizes the client’s
airway first,
followed by breathing,
circulation,
disability, and
exposure, so the first assessment the nurse should make is to ensure the client has an adequate airway.
The nurse should use the _____ restrictive/ ______invasive priority setting framework when caring for clients who are posing a threat to themselves or others, or when deciding on invasive versus non-invasive nursing interventions.
least
least
Before implementing restrictive or invasive measures, the nurse should attempt measures that are
least restrictive and least invasive but still maintain the safety of the client.
The nurse should use the survival potential framework when caring for groups of clients involved in
mass casualty accidents such as natural disasters or acts of terrorism.
The focus of the survival potential framework is to
provide the most good to the greatest number of clients with the resources available at the time.
The nurse should inform the newly licensed nurses that the survival potential priority setting framework, used during
mass casualty situations,
survival potential priority setting framework uses a color-coded system to
prioritize clients for treatment based on potential for survival. This priority framework seeks to provide the most good to the most clients with the resources available.
The nurse should inform the newly licensed nurses that the least restrictive/least invasive priority setting framework gives priority to nursing actions that are the
least restrictive, or least invasive while still maintaining the safety of the client.
The nurse should inform the newly licensed nurses that Maslow’s Hierarchy of Needs includes
client love and belonging needs, which can be met by encouraging social relationships and group interactions with personal friends and work connections.
The nurse should inform the newly licensed nurses that the safety and risk reduction priority setting framework assigns the highest priority to the
factor or situation that will cause the greatest harm to the client’s physical well-being.
Survival Potential Framework Assign aredtag to clients who
have life-threatening injuries but have a high chance of survival with immediate treatment (emergent; first priority for treatment).
Survival Potential Framework Assign ayellow tag to clients who
have an urgent condition that could wait a short time for treatment (urgent; second priority for treatment).
Survival Potential Framework Assign agreen tag to clients who
walking wounded, or clients who have injuries that are non-life threatening and could wait hours to days for treatment (nonurgent; third priority for treatment).
Survival Potential Framework Assign ablack tag to clients who
deceased or have a minimal chance of survival despite treatment, and promote comfort for these clients (expectant; lowest priority).
Criticalclient care needs require the nurse to
intervene immediately to prevent the client from deteriorating
EX of critical care
(e.g., respiratory difficulty, chest pain, or a change in neurologic status).
Urgentclient care needs are identified when the client could
suffer mild harm or discomfort if there is a delay in addressing the client’s needs
Ex of urgent care
(e.g., postoperative pain).
Routineclient care needs include tasks such as
administering routine medications and performing required shift tasks
Ex of routing care
(e.g., routine vital signs, daily physical assessment).
Extraclient care needs involve activities that are not
essential to client care but can promote client comfort
Ex of extra care
(e.g., providing the client with a warm blanket, combing the client’s hair).
BCDE (airway, breathing, circulation, disability, exposure) approach
A systematic method that can be utilized in any health care setting to evaluate and treat the client. ABCDE is the acronym for airway, breathing, circulation, disability, and exposure.
acute versus chronic
A framework in which acute conditions are prioritized over chronic conditions.
direct care
Client care activities that are performed at the bedside.
indirect care
Client care activities performed by the nurse away from the bedside.
least restrictive/least invasive
Interventions are selected that maintain client safety while producing the least amount of restriction to the client;the nurse chooses interventions that are the least invasive.
Maslow’s hierarchy of needs
A theory that suggests there are five categories of needs that motivate human beings. The five categories are psychological, safety, love and belonging, esteem, and self-actualization.
nursing process
A framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.
rationing
Process in which allocated resources are scarce and there will not be enough to meet all of the required needs.
resource allocation
The distribution of resources to a service or department.
safety and risk reduction
Priority is given to whatever finding poses the greatest or immediate risk to the client’s physical or psychological well-being.
survival potential
Priority is given to the client who has a reasonable chance of survival with immediate intervention. This framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage.
triage
To sort and rank treatment of clients according to the urgency of their need for care.
unstable versus stable
Priority is given to the client who has an unstable condition versus the client with a stable condition.
urgent versus nonurgent
Priority is given to the client who has an urgent need over a client with a nonurgent need.
